Clinical risk evaluation contributes to case finding and diagnosis of osteoporosis in postmenopausal women

Abstract

normal BMD, 48% (CI: 42-57%) of those with osteopenia and 50% (CI: 43-53%) of those with osteoporosis. Similar values were found in men and women and also if only patients with a fall from standing height had been included. We conclude that nearly one out of two patients with a recent nonspine clinical fracture have undiagnosed morphometric vertebral fractures when measured by MXA, even when BMD is normal. MXA significantly increases the number of patients with the diagnosis of osteoporosis, even when more stringent criteria (any H≤ 0.75) are applied. (1) Genant et al. JBMR 1993, 1137 P169. Secondary osteoporosis in patients with a recent clinical fracture and low bone mineral density Osteoporosis is a multifactorial bone disease that results in fragility fractures with significant morbidity, mortality, health-and social costs. Relatively little attention has been paid to the medical evaluation of patients with a clinical fracture. We therefore investigated bone-and fall-related risks for fractures along with causes of secondary osteoporosis in patients admitted to the hospital because of a recent clinical fracture. All patients older than 50 years, who presented at the hospital with a fracture, had fracture and fall risk evaluation according to the Dutch guidelines, including bone densitometry. Patients with a T-score ≤−2.5 in the hip and/or spine were further investigated for secondary osteoporosis. We evaluated 100 consecutive and consenting patients, 73 women and 27 men with a mean age of 68 years (50-90 years). Sixty-six had contributors to secondary osteoporosis. Forty-one patients had previously undiagnosed vitamin D deficiency (≤50 nmol/l), 28 had endocrine diseases (13 known thyroid pathologies, 1 primary, 5 secondary undiagnosed hyperparathyroidism (PTH >5.5 pmol/l), three men had unknown hypogonadism (testosterone <9.4 nmol/l), 14 had known renal insufficiency (creatinine clearance <40 ml/min)), six had inflammatory rheumatic diseases and four men had alcohol abuse. Thirty patients reported history of non-vertebral fracture and one history of a clinical vertebral fracture. On morphometry 61 patients had prevalent vertebral fractures. There were 54 patients with clinical fracture risks (73 when morphometry included), 79 had fall risks and 61 had both fall and fracture risks, including morphometric vertebral fractures. We conclude that secondary osteoporosis is frequent in patients entering the hospital with a recent clinical fracture and a T-score ≤−2.5. Nearly two in three had previously undiagnosed morphometric vertebral fractures. P170. Clinical risk evaluation contributes to case finding and diagnosis of osteoporosis in postmenopausal women Clinical case finding for those at risk of osteoporosis and fractures is advocated in all guidelines of osteoporosis, but its application in daily practice remains unsatisfactory. We studied the effects of clinical fracture risk evaluation on case finding and diagnosis of osteoporosis in postmenopausal women consulted by their general practitioner (GP). From 42,690 postmenopausal women age, weight and history of fractures after the menopause were recorded by 1,080 GPs. The OST index was calculated from age and weight as integer of (0.2 times [weight-age]). (1) An OST of >1 indicated low risk (LR), −3 to 1 moderate risk (MR) and <−3 high risk (HR). A prior DXA had been performed in 6,637 women (16%) in 7% in the LR, 22% in the MR and 26% in the HR. After clinical evaluation 10,841 (29%) additional women were sent for DXA (p<0.001 vs. number (16%) of those with prior DXA): in 8% of the LR, 47% of the MR and 72% of the HR (p<0.001 for distribution between risk groups compared to patients with prior DXA). New cases of osteoporosis in the spine and/or hip were found in 2,353 (7%) of all clinically evaluated patients and in 23% of those send for DXA (15% of the LR, 27% of the MR and 47% of the HR, p<0.001 between risk groups). A history of fracture after age 50 was present in 6,732 (16%) of all women (in 8% of the LR, 19% of the MR and 42% of the HR) (p<0.001). Altogether 27% of patients with a previous fracture had a prior DXA, compared to 13% of women without fracture history (p<0.001). After clinical evaluation, 66% of patients with a fracture history, but not having had a DXA, were sent for DXA (p<0.001). In these patients, 979 (32%) new cases of osteoporosis were diagnosed (21% in the LR 36% in the MR and 57% in the HR, p<0.001). In patients without a fracture history, 13% had a prior DXA. After OST evaluation, 24% S64 Osteoporos Int (2007) 18 (Suppl 1):S29-S175 additional women were referred to DXA (p<0.001 vs. prior DXA), 50% of the LR, 83% of the MR and 72% of the HR (p < 0.01). New cases of osteoporosis were diagnosed in 1,477 (20%) of those send for DXA (12% in the LR, 23% in the MR and 40% in the HR, p<0.001). We conclude that clinical screening in postmenopausal women using fracture history and the OST-index tripled the proportion of women referred for DXA, with a significant shift towards referring more women at high risk.